Primary Care Medicine and Some Medical/Ethical Issues
Authors: Brian P. Schwartz, MD, Director of Clinical Ethics, Kettering Medical Center, Kettering, OH; James J. Londis, PhD, Director of Ethics and Values Integration, Kettering Medical Center, Kettering, OH.
Peer Reviewers: Robert M. Arnold, MD, Director of Clinical Training, Associate Professor of Medicine, University of Pittsburgh Medical Center, Center for Medical Ethics, Pittsburgh, PA; Gerald M. Winslow, PhD, Dean, Division of Religion, Chair, Center for Christian Bioethics, Loma Linda University, Loma Linda, CA.
Editor’s NoteAlong with the explosion in medical science has come a similar explosion in ethical issues. The advances in medical science have engendered a corresponding increase in the ethical dilemmas facing physicians today. Additionally, the general public and special interest groups have become much more involved in these issues as medicine becomes less paternalistic and patients demand more autonomy and input into decision-making. This article, co-authored by an ethicist and a physician, examines the principles underlying ethical decision-making by practitioners and offers a practical guideline in dealing with ethical issues that face the clinician. In a future article, we will deal with challenges that face primary care physicians in dealing with HMOs while at the same time trying to play the role of the patient’s moral fiduciary advocate.
The public holds physicians to a moral standard for their work that often exceeds legal requirements. As anyone knows from Ethics 101, the moral and the legal are different. Slavery, for example, was once legal in the United States even though it was immoral. Women were legally kept from voting for centuries, even though we would now acknowledge the evil of that prohibition. Physicianswhose life-and-death decision-making profession exposes them to enormous risksmust also distinguish between the legal and the ethical in their practice. As we have seen in recent years, some physicians are willing to challenge the law on certain issues because they believe the law is immoral. This article should help clinicians be more ethically aware in their treatment of their patients.
Case #1: A 34-year-old female has been under your care for the last 10 years. For the last three years, she has been fighting metastatic breast cancer. Despite her being on chemotherapy and hormonal therapy, recent scans indicate that the cancer has spread to her liver. She now asks you whether anything else can be done. You think about the possibility of further therapy with a bone morrow transplant but quickly realize that her HMO will not cover experimental therapies. Furthermore, you know that the chances of success with that therapy are marginal. Do you tell her about this option? Or, do you simply reassure her that every reasonable option has been tried?
Case #2: A 42-year-old male comes into your office complaining of no urine output for the last 24 hours. Three days ago, he was in your office with a muscle strain in his shoulder. At that time, you gave him an injectible non-steroidal medication. The blood work that you obtained in the office reveals creatinine levels of 3.4, and you suspect interstitial nephritis caused by the non-steroidal medication. Do you now tell him that the deterioration in his kidney function might be due to the medication that you prescribed several days before? Or, realizing that this may be self-limited, do you simply advise him to come in for follow-up lab tests in hopes that this will resolve without causing further problems?
While the above cases are straightforward and unlikely to cause a major moral dilemma for most physicians, they do illustrate that physicians daily confront ethical issues. The principles that apply to straightforward cases will also help the physician address more complex ones.
A final case illustrates that an ethical dilemma may occur not with the physician but with the patient. For that reason, physicians also need to be adept at counseling and advising their patients who face their own ethical dilemmas.
Case #3: A 49-year-old Caucasian male presents to your office with penile discharge. A slide made of the discharge confirms that he has a chlamydia infection. You counsel him that he should inform his wife, as she may also need treatment. He confides in you that he has not had relations with his wife in several months but has been seeing a friend from work. He asks that you not tell his wife, who is also a patient in your practice and who is scheduled for an appointment in two weeks. What are your obligations to this man and his wife, both of whom are your patients? What counsel would you give to help him make the right decision in this dilemma?
As you read these cases typical of situations that confront the primary care physician, what mental steps did you take? What kind of reasoning did you employ to work through the issues? Did you start with the facts and details of the cases and then work toward a solution based on your general understanding of the moral atmosphere of our culture? Were you concerned more with the consequences than with the nature of the action itself? If so, you employed the kind of moral reasoning we call casuistry and may have employed a utilitarian method in your approach. Casuistry is an inductive approach that starts from the concrete facts of a case in the context of the moral rules people ordinarily use to make ethical decisions. It is not reasoning from general norms to particular cases. Using this approach, you would carefully weigh whether informing the female in case #1 about a bone marrow transplant would be appropriate given the facts of her case, her current feelings about her treatment, and the quality she wanted to have in the life remaining to her. There might be reason not to tell her about the bone marrow transplant option, although, even if it was hopelessly beyond her financial reach, we suspect that most physicians would mention it. Or, the physician might consider advocating on behalf of the patient with her insurance company, pressuring it to support this protocol.
Or, did you start with a theory of morality that would be applied to the facts? For example, if you assumed that every action is right or wrong in its own nature ("it is always wrong to lie, break a promise, steal, or commit a murder, regardless of the circumstances"), then you are probably a deductivist who thinks it relatively easy to determine right from wrong in a variety of situations, including those encountered in medicine. On this view, the physician would inform the patient in Case #1, regardless of the facts, on the basis that it is always a violation of patient autonomy to withhold important information as she tries to decide about her future.
Or, did you move between these two poles of moral decision-making in an effort to make them fit together and reinforce each other? Did you insist on having principles but not so inflexibly that they are imposed on the case without regard for its unique characteristics? Did you sense potential conflict between the principles and think about which of these principles would take precedence? If so, you are probably what is often referred to as a principlist.1-3
In more recent years, other ways of thinking about medical-ethical dilemmas have arisen, from a "care-based ethic"4 to "feminist medical ethics."5-7 Care-based theorists are working diligently on developing an ethic that arises out of the principle of "caring" rather than some of the more formal principles we will summarize momentarily. Feminist ethicists argue that the domination of medicine by males with their emphasis on competition, hierarchy, and abstract reasoning from formal principles cannot adequately resolve many of the moral dilemmas inherent in the care of patients. Further, they also insist that how one sees the patient and how one perceives the relationship between the physician and the care team, or the physician and the patient, is very different from the perspective of those historically at the "bottom" (females as nurses and physicians) in medicine than from those historically at the "top" (white male physicians). Feminists doing medical ethics want less hierarchy and more equality, a focus on the particularities of each case rather than on abstract principles, and each situation interpreted in terms of its effect on the relationships of the people involved.8
Because medicine often deals with people in extremis, or at least with people in pain and fearful about their health, every practicing primary care physician is familiar with the ethical challenges inherent in these cases. They are woven into the fabric of medicine so completely that it is difficultif not impossibleto make any decisions or recommendations about patient care that do not have ethical implications. For that reason, it is helpful for physicians to familiarize themselves with how current medical-ethical thinking affects the challenges they face every day. While there are a number of principles that are important to medical ethics, most modern ethicists recognize that at least these four basic principles in medical-ethical reasoning form the basis for most of their work. They have been employed in one form or another since the time of the Greeks.
1. Beneficence. Beneficence may be understood as that principle which impels the physician to "seek the patient’s good," to put the patient’s welfare above all that would compete with that welfare in the physician’s eyes, most especially the physician’s own good. Financial concerns, time constraints, managed care, government DRGsnothing can trump the importance of the patient’s welfare. In the fee-for-service system, one could afford to seek the patient’s good without fear of being challenged, if "good" is taken to mean do everything possible for the patient. If a physician had the slightest doubt about a diagnosis, more tests could easily be ordered. No one would challenge a physician decision regarding diagnosis or treatment. Today, one must "do good" in a way that does not unduly waste resources. Now, clinical quality indicators and standards of care are invoked by medical institutions as well as HMOs to somewhat regulate the doctor’s decisions about diagnosis and treatment. Recently, several celebrated cases in which HMOs refused to pay for either a lengthened hospital stay (obstetrics case) or for certain kinds of treatment modalities have been reviewed by the courts, thus reining in what some regard as excessive interference in medical treatment and patient care.
When a dispute is over what is in the patient’s best interest, including how one achieves it, ethical issues naturally arise. In Case #3 concerning the man having an affair, the dilemma is particularly acute because one patient to whom the physician owes loyalty and confidentiality is asking the physician to protect him at the possible peril of another patient who also trusts him. Differences of opinion may exist on how best to address that dilemma. Or, physicians may feel that "doing good" requires a "compromise" when a patient is uncooperative with the care plan. When a patient suffers from dangerously high cholesterol, for example, the physician may feel compelled to prescribe a cholesterol-reducing drug that has unpleasant side effects because the patient will not change his lifestyle. In other words, there is no "list" of what is "best" for a patient that a physician can mindlessly apply to each condition or situation. Judgment, imagination, and sensitivity are also needed. In the dilemma of Case #3, the physician may feel either that the principle of beneficence is best upheld by assessing which course of action will most likely produce the best short- or long-term consequences for the female patient, or that one’s obligation to the male patient requires that confidentiality be maintained.
2. Non-maleficence. Non-maleficence or "do no harm" is the second principle. This principle recognizes that when a patient places her very life in the physician’s hands, she has the right to expect that the physician will not harm her, and that any risks associated with treatment will be reasonable ones in relationship to the desired outcome. This is also the principle used to support the view that under no circumstances may a physician assist a patient who wishes to die. Physicians may withhold or withdraw treatment; they may even prescribe pain-controlling drug therapies that can shorten life. Such practices fulfill the "do no harm" criterion.
3. Patient autonomy. Patient autonomy is the next principle. This means that we must give the competent patient or her designated surrogate final decision-making authority over what will or will not be done to and for her by the physician. That is, no one can ever be forced to accept treatment she does not want, even if it is in her best interest. In the history of medicine, the importance of this principle is a rather late arrival. For several centuries, a heavy-handed paternalism operated in medical culture. Patients could be treated against their will if the physician deemed it appropriate. Some will argue that our anti-paternalism is a uniquely Americanor Westernprinciple given our highly individualistic democratic culture. Other parts of the world (Africa, for example) may not find this principle as compelling in their tribal or communal cultures. Because of our emphasis on autonomy, we have found it more difficult to deal with mentally ill people who refuse help and at the same time are not ill enough to be declared incompetent.
In 1840, John Stuart Mill argued against the absolute authority of a political sovereign and stated that he was sovereign over himself. This concept undergirds the contemporary bioethical principle of personal autonomy or self-determination, as well as much that is in American ethics and United States health care policy. This principle was applied in 1914 in the case of Mary E. Schloendorff v. The Society of New York Hospital which stated that ". . . every human being of adult years and sound mind has a right to determine what shall be done with his body; and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages." The principle of autonomy suggests that physicians should see themselves engaged in a cooperative program with their patients which provides information to them about treatment possibilities and then helps patients achieve the care that best coincides with their values. It cannot be "the doctor knows best" without qualification. While the doctor may know best about specific treatment options, how those options fit into the person’s life is best known by the patient. The ethical physician seeks to enhance a person’s autonomy in all medically important decisions.
It must be emphasized that physicians and patients are not equal agents freely entering into a simple contract. Because vulnerable patients are in a "fiduciary" relationship with physicians who, because of their knowledge as professionals, must protect their patients, only physicians committed to their patients best interests can be truly ethical. For example, as patients struggle to make informed decisions in their own best interest, physicians must learn when and how to balance the importance of autonomy against their occasional need for protection and help. When physicians face a dilemma with respect to the competency of a patient, for example, they must know when to turn to another adult who might serve as the patient’s decision-maker if the patient is unable to temporarily or permanently meet that goal.9 The physician can certainly contribute to the decisions, and the surrogate does not need absolute control but can act as a third party who looks after the patient’s interest.
A concept closely linked to patient autonomy is "competence." By definition, an autonomous or self-determining patient must be competent to understand his options and decide intelligently. To be competent, a patient must be able to understand the significance of the disease in question and its likely outcome. She must be able to process information about that disease and its treatment options. In order to be competent regarding a particular procedure or treatment plan, patients need only understand the implications for their particular treatment. They do not need to demonstrate competence in all aspects of their lives.
Many things can impair the patient’s competence and, therefore, his autonomy. Examples include: drugs and alcohol, mental duress such as depression, a deficit in cognitive functioning such as dementia, and diseases that impair the ability to think and process information. On the other hand, certain diseases can mimic impairment, thus making it difficult to determine competence, such as expressive aphasia. In addition, a language barrier or different social norms can cause certain patients to feel unable to express themselves. A physician needs to sort through each of these possibilities and make sure that the patient is in fact able to process the information relevant to his care and make his own decisions. If he cannot, then competency must be in question. In those intractable cases that leave a physician in doubt, one must occasionally resort to the courts for final disposition. However, a court will typically appoint either a physician, psychologist, or social worker to assess the patient’s ability to make decisions regarding her care. If it is felt that a mental illness is impairing a patient’s ability to make a competent and informed decision, then it may be wise to have a psychiatric consult to identify the extent of the impairment. If a patient is found incompetent, then treatment may continue if he has given an advance directive such as a Living Will stating clearly how he would want to be treated in different situations. Or, one might instead look to a Durable Power of Attorney for Health Care (which is recognized in most states), in which a patient appoints another person to express his wishes regarding his care. It should be noted that the Durable Power of Attorney for Health Care does not confer unlimited decision-making power on the surrogate. The surrogate is expected to follow the directions either given by the patient at an earlier time or to judge what he would have wanted given the way he lived his life and the values he embraced.
Without that, input should be sought from the patient’s next of kin, a practice typical in medicine and one supported by the courts. If there is a conflict about which person should exercise authority for the patient, one must resort to the court for appointment of guardianship. It is inappropriate for physicians to serve as surrogate decision makers because they are in a potential conflict-of-interest position. Like it or not, physicians have a vested interest and a natural bias in decisions that affect the life and well-being of their patients. We must also mention the importance of "listening" in the physician-patient encounter. Most of the time, patients reveal their values and wishes to their physicians in frequent and careful conversations.
Many primary care physicians will provide patient care in the "extended care" arena such as nursing homes. Patients in such settings are likely to feel an immediate loss of autonomyall the more reason to help patients retain as much control over their own lives as is possible in a given situation. Naturally, end-of-life issues confront the physician in this setting most frequently. Sensitivity to the patient’s and family’s wishes will often prevent misunderstanding and frustration in the last years of the patient’s life. For this population group it is especially important to have both a Living Will and a Durable Power of Attorney for Health Care. The Living Will does have limitations that may not address an individual patient’s wishes or needs. It may clearly address these issues when a patient is in a terminal condition, but many patients can linger on for years supported by artificial nutrition or other interventions. For that reason, it is important to know something about the patient’s values so that the following questions may be answered: What kind of life does this patient wish to live? If unable to reach those life goals, what type of interventions would he want? What type would he refuse?
Before we leave this subject, we should point out that there may be occasions when the patient’s wishes cannot be respected with regard to treatment. For the physician to justify exercising some paternalism and coercion, one must be clear that the patientwhatever reasonis not competent to make such decisions.
While physicians may have a point of view and should feel free to express it, under no circumstances is it ethically appropriate for physicians to impose their personal values about medical treatment on their patients. Whatever is most appropriate will have to be consistent with the values of the patients themselves.
Ethical dilemmas may even arise over a critically ill patient’s refusal of treatment when the physician knows that the patient can be helped. In such scenarios, as difficult as it may be, the physician’s task is to give the best medical advice and then help the patient or surrogate integrate that advice with the patient’s personal values. Thus, two patients with very similar problems may receive very different treatment based on their preferences. As an example, consider the cases described in the accompanying Case Study. (See pg. 234.)
It is therefore vital that primary care physicians spend some time reviewing with their patients how the patients’ values might affect their decisions with respect to any life-threatening illness they might face.10-11
4. Justice. Justice is the fourth principle. It is concerned about the fair distribution of health care resources when it is impossible for everyone to have everything "possible." It is the principle that compels moral beings to be concerned about the tens of millions of Americans without health care coverage, with the fact that prenatal care among poor women is considerably below the national average, and with the fact that in some circumstances (e.g., a major earthquake or flood), resources may need to be "triaged" between those who need immediate care to survive, those who cannot survive, and those whose needs are real but not life-threatening. In other words, it is the principle that prevents us from neglecting the powerless and poor and from wasting resources.
Assisted Death. Human dignity and the principle of patient autonomy includes the right to refuse various interventions and to determine one’s end-of-life needs.12-13 Although not specifically legal in many states, the physician may be asked to assist the patient who wishes to end his life. A "not-so- secret" secret in medical circles is the phenomenon of patients asking physicians for help in bringing their suffering to an end not by withdrawing or withholding treatment (which are both legal) but by administering a drug in order to kill the patient. The use of potentially deadly levels of morphine to control suffering in end-stage cancer patients is common and considered both legal and ethical, sinceas the "do no harm" principle illustratesits intended purpose is to reduce suffering, not kill the patient. In the opinion of many legal and ethical scholars, when the intention is the death of the patient, a line has been crossed that should never be violated by a medical doctor. Those who do assist provide help through information or prescriptions but not by actively "doing" anything to the patient. While such behavior has been attacked both ethically and legally, no jury has convicted any physician of a crime. This suggests that large segments of the population perceive such "help" as meeting a genuine need in some terminally ill patients.
"Assisted Death" or what used to be called "Physician Assisted Suicide" (an inflammatory and prejudicial phrase in the opinion of many; hence, the change) will be with us for some time to come.14-15 There are two primary reasons patients may ask for help in dying. The first is that in a very few instances, the physical pain cannot be relieved. In such a case, what is to be done? Some suggest that the patient "bear" the suffering bravely. Others believe that is cruel treatment. They assume that a "dignified" death is one made as tranquil as possible. A second, more widespread reason that people want help in dying is that they do not want to die a lingering death with the indignities associated with incontinence, memory loss, and dependence on family and health care workers. In their view, mercy and compassion require that we do all we can for people (or even animals) who are in suffering (physical, emotional, and spiritual) as they await their deaths.16-18 The recent Supreme Court decision has made it clear that terminally ill patients do not have a "constitutional right" to assistance in suicide. On the other hand, the same decision also made it clear that it is not "unconstitutional" for states to have legislation permitting it. One may expect that this dilemma in bioethics and the law will undergo intense debate in the coming years.
Palliative Care. In recent years, the various medical associations have been promoting the benefits of palliative care. It is now widely accepted that physicians need to become both familiar and comfortable with relieving the suffering of patients in their last weeks or months of life. Well- administered comfort care is part of the art of healing to which physicians are committed. While it may not eliminate the perceived need of some patients for physician assisted death, aggressive palliative and supportive care would clearly diminish the number of requests for physician involvement with dying.19-22
Many of the issues discussed above are not a daily challenge for a typical primary care physician. Nevertheless, as we saw in the first three cases of this article, primary care physicians are confronted on a daily basis with ethically significant problems. They may be as simple as giving informed consent regarding the side effects of a particular medication; or notifying the Health Department and exposed adults about a sexually transmitted disease problem. Issues of domestic violence like child or spousal abuse impose obligations on the physician to report these activities. In doing a disability evaluation with patients who hope to benefit financially from having a particular disease, questions may arise. Patients with psychosomatic illnesses can make the physician wonder whether it would be appropriate to give a placebo as a treatment for the disease process. A typical procedure being questioned is a placebo intravenous saline solution that is administered to patients with pseudo seizures. The patient is told that this medication will in fact induce one of their seizures. If the patient then has one, this is thought to confirm the diagnosis of pseudo seizures induced by the patient himself. Since this "test" requires deceiving the patient, its ethics have recently come into question.
The Values and Obligations of Physicians
Physicians as Persons of "Virtue." A crucial point made repeatedly in contemporary ethics is that acting ethically requires not just reasoning from principles or being committed to caring in each case, but also that the physician be a person of "virtue," someone who has nurtured feelings and dispositions like compassion, prudence, self-sacrifice, and respect for the autonomy of patients. We need morally sensitized physicians.14-15
Bioethics asks of physicians at least three questions about virtue: How important are ethics and values in your personal life?; How central is ethics in your relationships with your patients?; and, how do your values define your relationship with the wider society?
Physicians as Protectors of Patients. Since, as we have seen, physicians’ relationships with their patients almost always involve a power imbalance in which the patient is vulnerable, dependent, and often physically or emotionally "weak," the physician must be the kind of person who wields that power for the sake of the patient and not merely for his or her own benefit. It is for this reason that we say that in becoming a physician a person enters more than a career or means of employment. Rather, one adopts a vocation or "calling," which entails far more than the notion of a "contract." For many, the term "contract" sounds too impersonal and business-like. It fails to capture the almost "sacred" agreement made between the trained healer and the sick. For this reason, the agreement between the physician and the patient (and, by extension, the wider community) has even been characterized as a "covenant."23
One important way in which physicians and other healthcare providers protect their patients is by ensuring that their very personal medical information is kept as confidential as possible, something more and more difficult to do in the computer age. Patients can be harmed when their health problems are known by those who have no need nor right to know. Family integrity, job security, personal relationships, and self-esteem can suffer from a loss of confidentiality in the medical record. The need to maintain confidentiality is one of the strictest ethical and legal standards applied to healthcare institutions and the physicians who use them.
Physicians Have a Fiduciary Obligation. As professionals who possess knowledge and skills needed by the wider society, physicians offer their services in exchange for money. This places upon them a fiduciary responsibility that they cannot betray without betraying who and what they are as healers. That is one of the reasons why the sick must be treated regardless of their ability to pay. In recognition of this calling, physicians have traditionally taken an almost sacred oath that acknowledges the respect and trust vested in them by society.
One reason the physician has an almost "sacred" obligation to society is that no doctor gets his or her degree and license to practice without considerable sacrifice by a number of people. If one thinks of the mentors, professors, and teachers who sacrificed their time to instruct medical students, of an education heavily subsidized by public funds, and of the patients who allowed themselves to be "practiced on" for would-be physicians as they tried to understand the disease process and how to heal it, it seems clear that doctors owe a debt to society that only their best medical efforts can repay.
This trust from the public, which is so essential to the healer’s art, is not impregnable, however. Only when physicians’ lives and practices are governed by principles that will guide them through precarious situations can that trust remain strong. Because of the responsibility invested in physicians by the community, physicians must possess certain values and act on the basis of well-established principles.
The Physician’s Obligations to Society
Traditionally, physicians were obligated almost exclusively to their patients. In more recent years, society has imposed its own obligations on physicians. In matters of health and public welfare, physicians now have many duties and obligations to either society at large, the local community, or third-party payers. Physicians may also incur obligations voluntarily, such as signing up with managed care organizations. Their obligations may be mandated by state and federal legislatures, such as conforming to what is considered reasonable standard of care for a local community. Physicians should be aware of these specific mandates for their particular states. Let us note a few that can create conflicts with the ethical principles discussed earlier.
Reporting. While it is expected that physicians will promote patient autonomy, dignity, and privacy, physicians may face patient illnesses with grave public health implications. In such cases, the principles of "do no harm" and "do good" would supersede the principle of patient autonomy and compel physicians to report their knowledge to the appropriate authorities. As already noted, respect for the patient’s autonomy may be overridden when physicians can show that doing so either meets more important obligations to others or has far greater benefits for the larger society. Besides the issues surrounding sexually transmitted disease, suspected child abuse or neglect, patient threats against another person, or clearly impaired driving ability may also override the principle of patient autonomy. Further, some states require the notification of the Bureau of Motor Vehicles if a physician encounters an impaired patient. In all such instances, the physician’s prima facie responsibility to the patient is superseded by his or her greater responsibility to others who are endangered and defenseless because of ignorance or immaturity. Another way to think through this issue is to point out that the burden imposed on the patient whose autonomy has been compromised is not as great as the burden placed on society if that autonomy is not set aside in these circumstances.
Signing Contracts. In this age of managed care, which has itself created numerous ethical dilemmas, physicians must be alert to the dangers that accompany the signing of managed care contracts which seek to control costs and care plans. Such contracts are filled with ethical issues. (See sidebar, pg. 236.)
It is incumbent upon physicians that they inform their patients of any and all limitations for treatment imposed on them by such contracts. This is becoming more acute in the managed care environment, which seeks to control costs by controlling treatment and care plans.
Use of Resources and Futile Care. Another socially significant ethical issue is this: When is it appropriate for physicians to refuse to give specific kinds of treatment which, medically, will "do no good" and waste valuable resources? This ethical challenge is not well understood because it is less frequently encountered by physicians than are end-of-life issues such as DNAR orders. It is often referred to as "futility" of care. When physicians believe that a treatment would be futile to administer at the same time the patient or the patient’s surrogate insists that it be administered anyway, the physician is confronted with an ethical dilemma. If and when physicians invoke the argument from futility as a justification for not using a particular therapy, the notion of futility should be narrowly defined. If we remember that the physician’s primary obligation is to the patient, then it may be difficult to justify withholding services out of a concern that resources not be wasted. While resource management is a legitimate concern that affects us all, it is a concern that must be addressed at the societal level through legislation. It is inappropriate for society to expect physicians by themselves to manage health care resources as they treat patients. This is not to deny that it may be justifiable for a physician to refuse to deliver a therapy or intervention. If, in the clinician’s judgment, no benefit would accrue to the patient in relation to the patient’s goals, this might justify refusal. The last point is crucial: What is the patient’s goal? To get well? That may be impossible. To stay alive until his daughter arrives? That may be doable and, therefore, the treatment not futile. However, it is one’s view of the sanctity of life that most affects his concept of what is "futile." Some believe that if the result of treatment will be life without self-awareness, it is futile. Others believe that life of any kind has quality, and it is therefore not futile. Clearly, this morally sensitive matter is reduced to a judgment call which can only be made by physicians in consultation with patients or their surrogates.
Besides the need to demonstrate that a planned therapy is of no benefit in treating a patient’s disease process, we must also show that providing that therapy imposes a "burden" either on the patient, the family, the physician, society, or the institution involved. An example of a futile therapy may be the administration of an antibiotic for treating a viral upper respiratory infection. Let us suppose that the physician believes this therapy contains no benefit, but the patient wishes to proceed with it. The patient’s desire alone may justify using it. But, since the therapy also exposes the patient to the risks associated with a medication’s possible side effects and allergic reactions, and since the therapy may pose a public health risk by contributing to the adult antibiotic resistant bacteria, the physician may be justified in refusing to provide the antibiotic. Despite the demands of the patient, the arguments from futility and increased public risk might be sufficient. Alternatively, providing a ventilator therapy to a terminal patient may or may not be futile depending on the values of the patient. If the patient passionately values life, even diminished life, a few additional days on the ventilator may be justified regardless of the lack of any perceived benefit to the patient. Providing the ventilator imposes a burden on the caregivers and society at large, but whether removing that burden is of greater overall value than several days of additional (diminished) life for the patient is almost impossible to judge. This is all to say that at least in some instances physicians should not use the concept of futility to deny care to their patients.25
It is the conviction of some authors that the concept of "futility" is often misapplied.26 Other ethicists believe that "futility" by itself is not a helpful concept. The physician must ask the patient and family: "What are your goals in treatment?" If the goal is lengthening of life to say goodbye to the family rather than "cure," a treatment might not be futile. If used at all, the concept should be used cautiously. However, there is no doubt that society must enter into serious discussion of how best to allocate our increasingly scarce resources. To do so will require a serious look at the issue of how we are to value one human life against another if we cannot save everyone. Is the dying elderly patient as or more important than the pregnant teenager who needs pre-natal care?
Ethics Committees and Consultants. Because of the requirements of the Joint Commission on the Accreditation of Healthcare Organizations that some mechanism be established in hospitals and other healthcare institutions, many hospitals have established an ethics committee. Historically, such committees have provided policy development and oversight with respect to end-of-life decisions (e.g., DNR), ensured that adequate and continuing education on ethical issues takes place for the hospital staff and its physicians, and engaged in case review or case consultation to help mediate conflicts and resolve the ethical challenges facing families, patients, and their caregivers. Most of their time and effort is given to policy development and education, not consultations. These committees usually consist of physicians, nurses, chaplains, social workers, trustees, administrators, an "outside" impartial attorney, and community representatives.
The strength of the committees is their breadth of perspective as they wrestle with the issues and seek to educate themselves and then the rest of the institution. Physicians on the committee serve the role of educating the lay members about the clinical and ethical issues surrounding medicine and providing their unique insights and experience to the discussion. The weakness of the committees is that most cases for which a physician might seek counsel need prompt attention, something difficult to provide at the committee level. This has resulted in either a small subcommittee (available at a "moment’s notice") responding to case inquiries or a consultant educated in medical ethics. Where there is a teaching hospital, very often a physician-ethicist or a philosopher-ethicist is available to help with the case, either informally or more formally by writing the consult in the medical chart. All physicians are exposed to the ethical dilemmas in medicine. Consultants are usually called for when disputes arise between the care team and the patient or family, or between care team members. They may mediate, arbitrate, educate or all three, depending on the situation. As primary care physicians, you are well advised to take advantage of whatever ethics resources exist in the institutions you serve. This will help you resolve delicate situations, stay within the law and the code of ethics, and give you the satisfaction of knowing you did all that was within your power to care for your patients in the most responsible and caring way.
The principles discussed above provide guidance to the practicing medical professional. They will help keep a physician from getting stuck in an ethical quagmire, with this caveat: Ethical principles are no substitute for the virtuous physician. Physicians may do the right thing for the wrong reason. When students begin their careers in medicine, we as a profession must model those virtues which are to govern the way a physician practices regardless of the restraints, legal system, or an ethics committee. If physicians foster a genuine respect for persons, especially the most disadvantaged members of society, if they manifest an interest in the patient as a person and not just as a diseased body, many modern healthcare dilemmas could be avoided. Further, because we live in a pluralistic society comprised of a bewildering plethora of cultures, religions, and value systems, the practice of quality medicine requires us to discuss seriously with our patients what their values and beliefs are. Even now, a program to teach spirituality and values in medical school is being funded by the Templeton Foundation. Because we can no longer treat every patient with a similar disease in the same way or assume we know what is best for each patient, it is imperative that physicians have a basic understanding of ethical principles and ethical reasoning and be able to articulate a justification for their actions in reference to a moral framework. The years of physicians "knowing what’s best" are over. We can only claim to know what is "best" in treating disease, not what is best in treating the patient as a person. We can only know what is best in concert with our patients and their families and in cooperation with the society at large.
References
1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 3rd ed. New York: Oxford University Press; 1989.
2. The Encyclopedia of Philosophy. USA: Macmillan; 1967;1:69-134.
3. Reich WT (ed). Encyclopedia of Bioethics, revised ed. Vol. 1-5. New York: Simon & Schuster Macmillan; 1995.
4. Fry ST, et al. Care-based reasoning, caring and the ethic of care: A need for clarity. J Clin Ethics 1996;7:41-47. See also J Clin Ethics 1992;3:8-20.
5. Tong R. Feminist Approaches to Bioethics. Boulder, CO: Westview Press; 1997.
6. Wolf SM (ed). Feminism and Bioethics: Beyond Reproduction. New York: Oxford University Press; 1996.
7. Holmes HB, Purdy LM (eds). Feminist Perspectives in Medical Ethics. Indianapolis, IN: Indiana University Press; 1992. See also J Clin Ethics 1996;7.
8. Gilligan C. In a Different Voice: Psychological Theory and Women’s Development. Cambridge: Harvard University Press; 1982.
9. Parker LS, Buller TG. Case study: A hard policy to swallow. Hastings Center Report. 1994;July-August:23-24.
10. Zawacki BE. The "futility debate" and the management of Gordian Knots. J Clin Ethics 1996;6:112-127.
11. Callahan D. The Troubled Dream of Life. New York: Simon & Schuster; 1993.
12. Luce JM. Withholding and withdrawal of life support: Ethical, legal and clinical aspects. New Horizons 1997;5:30-37.
13. Medical Ethics Advisor. Nourishment or punishment: When should tube feeding stop? 1997;June.
14. Pelligrino ED, Thomasma DC. The Christian Virtues in Medical Practice. Washington, DC: Georgetown University Press; 1996.
15. Lown B. The Lost Art of Healing. Boston: Houghton Mifflin Co.; 1996.
16. Nelson HL. Death with Kantian dignity. J Clin Ethics 1996;7:215-221.
17. Hendlin H, et al. Physician-assisted suicide and euthanasia in the Netherlands: Lessons from the Dutch. JAMA 1997;277:1720-1723.
18. Vorenberg J, Wanzer SH. Assisting suicide. Harvard Magazine 1997;March-April:30-ff.
19. The Journal of Law, Medicine & Ethics 1996;24:4.
20. Henry S. Should doctors help patients die? HIPPOCRATES 1997;August:26-28.
21. Weber DO. Healthcare Forum Journal 1995;March/April:14-25, 85.
22. Shapiro RS, Derse AR, Gottlieb M, Schiedermayer D, Olson M. Willingness to perform euthanasia: A survey of physician attitudes. Arch Intern Med 1994;March 14:575-584.
23. May WF. Testing the Medical Covenant. Grand Rapids, MI: William B. Eerdmans Co.; 1996.
24. The Protector. 1997;2nd Quarter:7.
25. Daniels N. Meeting the challenges of justice and rationing: Four unsolved problems. Hastings Center Report 1994;July-August:27-29.
26. Morreim EH. Profoundly diminished life: The casualties of coercion. Hastings Center Report. 1994;January-February:33-42.
Physician CMEQuestions
57. The physician-patient relationship is "fiduciary" because:
a. there is a power imbalance in the relationship due to the physician’s greater knowledge.
b. the physician owes something to the patient but nothing to society.
c. the patient (or someone else) "pays" the physician for services.
d. the law decided that the relationship is fiduciary.
58. The principle of patient autonomy means that:
a. the doctor knows best.
b. the patient knows best.
c. the patient’s wishes cannot be violated.
d. the patient is free to decide whether or not he or she will accept treatment.
59. Ethics committees are helpful because:
a. they take the onus for decision making off the physician.
b. they take the onus for decision making off the family.
c. they help mediate conflicts between patients, families, nurses, and physicians and can make unbiased recommendations on matters of ethical importance.
d. they can protect the hospital from lawsuits due to misunderstanding the physicians and other caregivers.
60. Physicians may justifiably subordinate patient autonomy when:
a. patient desires are in conflict with the physician’s desires.
b. patients indicate that they wish the doctor to "make all the decisions."
c. the patient’s condition poses a threat to the health of the community.
d. the law demands to know specific information about a patient for reasons unknown.
61. Feminist bioethicists believe that:
a. abstract principles are the most important element in bioethics.
b. power issues, relationships, and caring are essential to an adequate bioethics.
c. women make better physicians than men.
d. men do not respect women in medicine.
62. Ethical issues involved in the signing of managed care contracts by physicians include which of the following?
a. Contracts that limit to whom patients can be referred
b. Contracts that deny a physician the right to indicate treatment modalities not covered by managed care
c. Contracts that deny experimental drugs or other therapies for apparently untreatable conditions
d. Contracts that limit what ancillary services can or cannot be used
e. All of the above
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